2016 of the · the catheter was sutured to the skin with silk suture. catheter care was provided by...

Diagnostic Radiology Program

Educational Symposia

RLI credits will be available for some sessions.

Florida Radiological Society

Florida Radiology Business Management Association

Saturday, August 6, 2016

The Ritz-Carlton, Amelia Island Amelia Island, Florida

The Light at the End of the Tunnel: Train or New Beginning?

ANNUAL MEETING OF THE2016

TABLE OF CONTENTSSATURDAY, AUGUST 6, 2016

Legislative Update (Alison Dudley) ........................................................................................................... 39

ACR Update (Timothy L. Swan, M.D., FACR, FSIR) ....................................................................................... 45

The Steven G. Miles Keynote Socioeconomic Address: Darwin Meets Roentgen: Don’t Count on an Invisible Hand-Out (Richard Duszak, M.D., FACR, FRBMA) .................... 51

Back to the Future - The Impact of the 2016 Federal Elections on U.S. Radiology (Frank J. Lexa, M.D., MBA) ............ 65

Imagining the Future of The Radiologist: Opportunities and Challenges (Garry Choy, M.D., MBA) ............................ 73

De-Commoditizing Radiology: Is it Possible and Should You Do It? (Frank J. Lexa, M.D., MBA) .............................. 83

Non-Physician Providers: Opportunities for Radiology in the New Team Based World (Richard Duszak, M.D., FACR, FRBMA).................................................................... 91

Why Is Culture Change So Difficult and Yet So Important (Lawrence R. Muroff, M.D., FACR) ................................. 105

Darwin Meets Roentgen: Don’t Count on an Invisible Hand-Out

Richard Duszak, MD, FACR, FSIR, FRBMA Professor and Vice Chair for Health Policy and Practice

Department of Radiology and Imaging Sciences Emory University School of Medicine

Disclosure

I receive research support from the Harvey L. Neiman Health Policy Institute.

Wilhelm Conrad Roentgen

  1845-1923   German engineer and physicist   In 1901, earned the first Nobel Prize in Physics for his

work producing and detecting the X-ray

“I have seen my death!” Anna Bertha Roentgen, 1895

Charles Darwin

  1809-1882   English naturalist and geologist   Best known for his contributions to evolutionary theory,

establishing that all species of life descended over time from common ancestors

“It is not the strongest of the species that survives, nor the most intelligent,

But the one that is most adaptable to change.”

Adam Smith

  1723-1790   Scottish philosopher and economist   Laid the foundations of classical free market economic

theory

“The Invisible Hand”

Self-interested competition tends to benefit society as a whole

by keeping prices low and incentivizing innovation and economic development.

Their Paths Never Crossed

1710 1720 1730 1740 1750 1760 1770 1780 1790 1800 1810 1820 1830 1840 1850 1860 1870 1880 1890 1900 1910 1920 1930

(1723-1790)

(1845-1923)

(1809-1882)

Adam Smith

Charles Darwin

Wilhelm Roentgen

53

How Doctors Get Paid The Good Old Days

The Great Society Structured Pricing

  UCR   Usual, Customary, and Reasonable

  RBRVS   Resource Based Relative Value System

$ CF W-RVU

X W-GPCI

PE-RVU X

PE-GPCI

ME-RVU X

ME-GPCI

Structured Pricing

  UCR   Usual, Customary, and Reasonable

  RBRVS   Resource Based Relative Value System

$ CF W-RVU

X W-GPCI

PE-RVU X

PE-GPCI

ME-RVU X

ME-GPCI

What Do We Want to Pay For?

54

What Does CMS Want to Pay For?

Medicare fee-for-service payments •  85% tied to quality or value by 2016 •  90% tied to quality or value by 2018

All Medicare payments •  30% through alternative payment models by 2016 •  50% through alternative payment models by 2018

How Do We Currently Determine Value?

  RBRVS   Resource utilization

But, Is That Really Value?

Value = Quality Cost

Perspectives Matter!

Porter ME & Lee TH. Harvard Business Review, October 2013.

•  The health outcomes achieved…

•  That matter to patients… •  Relative to the cost of

achieving those outcomes

Lower Cost

Hig

her Q

ualit

y

Fee for Service

Accountable Episodes

Pay for Performance

Lower Cost

Hig

her Q

ualit

y

Fee for Service


Pay for Performance

55

What is Fee for Service? FFS Paid on Best Practice Basis

$8.85

Fee for Service = Fee for Volume

$8.85

Why the Disconnect?

•  Limited quality transparency •  Payer-consumer disconnect •  Supply-driven utilization

What Would They Think?

Lower Cost

Hig

her Q

ualit

y

Fee for Service


Pay for Performance

56

Lower Cost

Hig

her Q

ualit

y

Fee for Service


Pay for Performance

The Devil’s in the Details

Value = Quality Cost

PQRS: Common Radiology Metrics

  All process based (i.e., not outcomes based)

  Specific metrics:   CT or MR for stroke: Documentation of hemorrhage, mass,

infarct   Carotid duplex for stroke: Stenosis reported in reference to

distal ICA diameter   Fluoroscopy: Documentation of radiation dose or exposure

time   Central lines: Documentation of maximal sterile barrier

technique   Mammography: Screening mammograms reported as

“probably benign”   Bone scan: Documentation of correlation with relevant imaging

PQRS Documentation

CLINICAL HISTORY Chronic renal failure, with failed dialysis fistula, and hyperkalemia. Central venous access was requested for urgent hemodialysis. PROCEDURE The procedure, options, and risks were reviewed. Maximal sterile barrier technique was utilized. After local anesthesia with 1% lidocaine, using real-time sonographic guidance, 21 gauge single-wall needle access was easily achieved into the right internal jugular vein using an anterior approach. The tract was converted with a micropuncture set to allowing introduction of a J wire down into the inferior vena cava under fluoroscopic control. The tract was dilated to allow introduction of 16 cm long triple lumen hemodialysis catheter. The catheter was sutured to the skin with silk suture. Catheter care was provided by the hospital staff. There were no immediate complications. Total fluoroscopy time was 0.4 minutes. COMMENT The right jugular vein is patent and easily compressible. After placement of the central venous catheter, as described, the tip is seen fluoroscopically at the level of the right atrial and superior vena cava junction. Fluoroscopy demonstrates no evidence for pneumothorax. Permanent images were obtained. IMPRESSION Uncomplicated imaging guided placement of temporary hemodialysis catheter.

PQRS: Early National Results

  Mean DR bonus in 2010: $2,811.39

  Qualified for bonuses:   23.7% of radiologists   16.3% of non-radiologists

  Registry reporting better than claims-based   Odds ratio 4.40 (95% CI 4.03-4.80)

Duszak R, et al. JACR 2013; 10: 114-121.

What Would They Think?

Duszak R, et al. JACR 2013; 10: 114-121.

Without physician, practice, or program changes over 75% of radiologists may face mean penalties

of at least $2,654 in 2016 totaling an estimated $111,393,067 for the entire profession!

57

What Measures Matter? Let’s Measure Stuff that Matters

Dose Matters To Us!

Flug J, et al. JACR 2016..

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Radiologists Non-Radiologists

Medicare abdominal computed tomography “double scan” rates by specialty group.

Lower Cost

Hig

her Q

ualit

y

Fee for Service


Pay for Performance

Lower Cost

Hig

her Q

ualit

y

Fee for Service


Pay for Performance

The Inpatient Hospital Episode

  Focus of most “episode of care” bundled payment interest   Metrics du jour have focused on hospitals

  Length of stay   Readmissions

  Physicians have still been paid under FFS

58

Inpatient Spending Distribution

Graphic from Komisar HL, et al. “Bundling” Payment. Center for American Progress, 2011.

Most spending in hospitals is for

hospital services

Physicians don’t matter much, right?

Physicians Matter a Lot!

  Many policy makers miss the real cost (and value) of physicians   Yes, they don’t directly cost a lot, but   They’re calling day to day health care

shots!

Physicians Matter a Lot!

  Many policy makers miss the real cost (and value) of physicians   Yes, they don’t directly cost a lot, but   They’re calling day to day health care

shots!

  Who has control over   Use of hospital services?   Involvement of other physicians?   Likelihood of readmission?   Appropriate use of post-acute care?

  Physicians!

Perspectives on Slicing the Pie

  It will all soon be one big pie!

14%

Total Health Care Spending

Physician Other

Re-slicing the Pie

  What if we could cut waste and inefficiencies by 15%?

12%

15%


Physician Savings Other

Re-slicing the Pie

  Opportunities for savings

12%


Physician Savings Hospital

59

Bundled Payments are Here Now What Would They Think?

How To Lead Data and Information!

But Where are the Tools?

www.neimanhpi.org

ICE-T: DRG Ranking Tool ICE-T: Medicare Cost Estimator

60

ICE-T: Professional Share Estimator Armed with Information

Geography Matters The Extremes

Neiman Almanac at www.neimanhpi.org

Florida

Ohio

Don’t Forget Turf

Rosman DA, et al. AJR 2015; 204: 1042-1048.

Or, Regional Change Rates

Rosenkrantz AB, et al. AJR 2015; 205: 817-821.

61

Big Spending Means Big Opportunities

Main T & Slywotzky A. The Volume to Value Revolution, 2012.

CareMore approach to Medicare Advantage population health management

Spiraling Savings

Focus on Top Tier

Focus on Lower Tier

Focus on Yet Lower Tier

Resources Savings

$ $

Profit Reinvestment

$

And So On

Quality

Cos

t Low Quality High Cost

High Quality High Cost

Low Quality Low Cost

High Quality Low Cost

Accountability is Key

•  Appropriateness •  Safety •  Efficiency •  Satisfaction

Quality Safeguards are Critical

  Process driven   Accreditation   Procedures   Reporting

  Outcomes driven   Immediate   Short-term   Long-term

  Transparency   To payers   To consumers

Report Cards

  You may not be getting them yet   But, you will increasingly be graded

My Report Card: Physician Compare

62

What Would They Think? Payment Systems are Evolving

It is not the strongest of physicians that survives, nor the most intelligent, but the

one most responsive to change.

63

Copyright: Frank J. Lexa, M.D. M.B.A., 2016

Frank J. Lexa, M.D., M.B.A. Professor, Spain and Asia Regional Manager the Global Consulting

Practicum, Professor of Marketing(adj.), the Wharton School

Chief Medical Officer, The Radiology Leadership Institute and Chair, Practice Leaders Commission, the American College of Radiology

Back to the Future- The Impact of the 2016 Federal Elections on U.S. Radiology


Facing Change: Myths and Reality Change is inevitable- true Change is always bad- false Change is always good- false


Federal Shock: Strategic Challengesfor US Radiology-2016

•  How is value measured and rewarded as FFS is phased out

•  Federal reimbursement •  Private shadowing •  Unreimbursed care •  Declining support for medical training-

particularly specialists


Federal Shock: Strategic Challengesfor US Radiology-2016

•  Degradation of independent private practice

•  Power shift from physicians to hospitals

•  Shifts to hospital employment •  Shifts to corporate employment in

national teleradiology companies •  Loss of outpatient imaging •  Turf battles


ACR Advocacy-2016 •  Lung screening •  MPPR •  MIPS •  Mammo wars •  Self referral and turf •  RUC, ICD and CPT •  CDS •  …


The election as of today

•  Current president is a lame duck •  Supreme court is one justice short and

effectively split 50/50 with regard to party line voting

•  Congress •  House has 246 Republicans out of 434 (one

vacancy as of this writing) •  Senate has 54 Republicans, 44 Democrats and 2

independents who usually vote with Democrats •  Governors- 31 Republicans, 18 Democrats,

1 Independent

67


The election as of today

•  Presumptive Republican Party candidate-Donald Trump

•  Presumptive Democratic Party candidate-Hillary R. Clinton


Meet the candidates


Clinton Biography

•  B. 1947 in Chicago. •  Wellesley then Yale Law. Staffer on

Judiciary Committee of the house during Nixon impeachment hearings. Taught law in Arkansas, later attorney in private practice.

•  First lady of the United States •  2001-elected Senator from NY •  Lost primary bid for presidency in 2008 •  Secretary of State 2009-2013


Trump Biography

•  B. 1946 in Queens. Billionaire real estate developer, TV personality -controversial how much value created given inherited wealth

•  No elected positions in government-explored running for president in 2000 as a Reform Party candidate

•  College: Fordham then transferred to Wharton undergraduate for final two years


The presumed candidates have some things in common:

Both will have survived a difficult and bitter primary process

Both have high negatives with the electorate-

dissident and 3rd party risks are real


This will be a historic election..

68


Wildcards

Third party candidacy

Record low (or high) turnout

Candidate withdrawals

Candidate substitutions at the conventions

Opposition research- treasure trove:TaxesNational securityHoward Stern tapes…


Candidate Clinton on health care •  As First lady worked on CHIP •  Will defend Affordable Care Act •  Increase tax credits on exchanges and limit % of

income to health care to 8.5% •  State incentives to expand Medicaid •  Outreach to increase Medicaid enrollment •  Exchange participation regardless of immigration

status •  Develop “public option” •  Reduce copays, deductibles and drug prices •  Support value and quality mechanisms

https://www.hillaryclinton.com/issues/health-care/ accessed 5/5/2016


Candidate Trump on health care •  Repeal Obamacare, especially individual mandate •  Free market principles, ie. remove state

boundaries to health insurance •  Full tax deductibility of consumer health insurance •  Expand HSAs and allow rollover •  Price transparency •  Block grant Medicaid •  Reduce regulatory blocks on drugs and devices

https://www.donaldjtrump.com/positions/healthcare-reform Copyright: Frank J. Lexa, M.D. M.B.A., 2016

Scenarios

•  Hillary wins, Congress stays Republican •  Hillary wins, Senate flips to Democratic •  Hillary wins, Senate and House are Democratic

•  Donald wins, Congress stays the same or slightly more Republican

•  Donald wins, but Senate flips to Democratic •  Donald wins but Senate and House are Democratic


Big questions that will affect the answers

•  VP decisions •  Third party candidates •  Fractiousness of the conventions •  Turnout on election day

•  How many people •  Who ends up voting


Implications for radiology

•  Increase versus decrease in Federalization of healthcare •  California example

•  Consumer choice versus narrow networks versus no choice •  Single payer is possible if the “public option” is enacted •  Micro-regulation versus capitation •  Speed of shift to value based purchasing and what value is

measured and rewarded

69


A perspective on Value: The McNamara Fallacy

1. Measure whatever can be easily measured 2. Disregard whatever cannot be measured easily 3. Presume that whatever cannot be measured easily is not

important 4. Presume that whatever cannot be measured easily does not

exist

Coined by sociologist Daniel Yankelovitch, cited at http://chronotopeblog.com/2015/04/04/the-mcnamara-fallacy-and-the-problem-with-numbers-in-education/ accessed on 3-23-2016


A perspective for Radiology Leaders in 2016

“Though much is taken, much abides, and though we are not now that strength which in old days, moved earth and heaven; that which we are, we are; One equal temper of heroic hearts, made weak by time and fate, but strong in will to strive, to seek, to find, and not to yield.”

-Tennyson, “Ulysses”


What should we do? 1.  Like Chicago (and Philly) Vote early, vote often 2.  Be involved in the other elections-

Congressional, state and local candidates matter

3.  Pay very close attention- this election will matter for radiology

4.  Build credibility and bring data-Harvey Neiman Policy Insitute, Comparative Effectiveness Data etc.

5.  Keep perspective

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Garry Choy MD MBA

•  Chief Medical Officer, Tesla Health

•  No other disclosures

• 

• 

• 

• • • • • • 

• • • • • • • • • • • • 

  

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CONCEPT CLASS

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• 

• 

• 

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Automated Detection, Localization, and Classification of Traumatic Vertebral Body Fractures in the Thoracic and Lumbar Spine at CTFrom the Department of Radiological Sciences, University of California–Irvine, Orange, Calif

The fully automated computer system detects and anatomically localizes vertebral body fractures in the thoracic and lumbar spine on CT images with a high sensitivity and a low false-positive rate.

Conclusion

92 percent sensitivity for fracture detection and localization to the correct vertebra.

• 

• 

• 

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• • • • • • 

80

• • • • • • 

• • • 

• 

• • 

• 

• 

• • • • • 

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Frank J. Lexa, M.D., M.B.A. Professor, Spain and Asia Regional Manager the Global Consulting

Practicum, Professor of Marketing(adj.), the Wharton School

Chief Medical Officer, The Radiology Leadership Institute and Chair, Practice Leaders Commission, the American College of Radiology

Decommoditizing Radiology: Is it possible and should you do it?


Learning Objectives 1.  Understand why the measure of our value has changed

2.  Develop strategies for creating new value, measuring and documenting it and getting credit for it

3.  Prepare for radical changes in our practices


Facing Change: Myths and Reality Change is inevitable- true Change is always bad- false Change is always good- false


Traditional Sources and Measures of Value in Radiology

1.  Fee for service- professional fee

2.  Technical component or share of global

3.  Management fees, medical director fees, etc.

4.  Direct and indirect payment for educational and research efforts


Problem #1 Decline in Fee for Service Dx Rad Reimbursement


Problem #2- The shift to value is on

HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.

News Release, HHS, Jan 26, 2015, www.hhs.gov/news

85


Value versus Volume

Copyright: Frank J. Lexa, M.D., MBA, 2012

“FFS is the dominant physician payment method in the United States,[1] it raises costs, discourages the efficiencies of integrated care, .”

- 1 Robert A. Berenson & Eugene C. Rich (June 2010). "US approaches to physician payment: the deconstruction of primary care". Journal of General Internal Medicine 25 (6): 613–618 .

http://en.wikipedia.org/wiki/Fee-for-service


Do Health Care Expenditures Create Value?

Copyright: Frank J. Lexa, M.D., MBA, 2012

“There is no correlation between the heightened spending and the health of the country’s citizens.”

- Lei Haihao, deputy director general of the Beijing Health Bureau

Burkitt L. China Calls for Health System Overhaul. WSJ. July 25, 2012:A10.


Measuring Value?

The are over 1000 hospitals in the US that currently market themselvesas being “Top 100”-1

1-The Digital Doctor- Robert Wachter page 40

There are only 5,686 hospitals in the US


Core question- can the value of radiology be increased?

1.  If not then we devolve to being a commodity?


Definitions

Commodity: Is uniform in quality between companies that produce/sell it. You cannot tell the difference between one firm's product and another1

Ergo: Lack of Product or Service Differentiation QED: Traded solely on price

1-http://economics.about.com/od/commodityprices/f/commodity.htm 2-4-12


Throwing Down the Gauntlet

We suggest that Medicare immediately expand the current program nationwide. As soon as possible, Medicare should extend competitive bidding to medical devices, laboratory tests, radiologic diagnostic services, and all other commodities.12 Medicare's competitively bid prices would then be extended to all federal health programs.13 To oversee the process, we recommend that Medicare establish a panel of business and academic experts. Finally, we recommend that exchanges — marketplaces for insurance starting in 2014 — conduct competitive bidding for these items on behalf of private payers and state employee plans. N Engl J Med 2012; 367:949-954September 6, 2012DOI: 10.1056/NEJMsb1205901 Authors on next slide

86


Should Radiology be a Commodity?

Commodities are often the result of failures: –  Failure of management –  Failure of imagination –  Failure to innovate –  Failure to understand a market –  Failure not just of you, but of your

competitors –  Form of group failure in a marketplace


What Could Drive the De-commoditization (increase the value) of

Radiology? ACO’s and related novel forms of practice that move from volume to value based purchasing

(Maybe) Re-thinking the value chain of what we can and should do

Innovation

Innovation

Innovation


Formal Structures that Address Value and Volume

•  ACO- Medicare Shared Savings Model-Federal

•  ACO-Pioneer Model •  Private sector ACO •  CCO •  Comprehensive Primary Care Initiatives •  Bundling Contracts •  Other forms of at risk contracting Copyright: Frank J. Lexa, M.D. M.B.A., 2016

Real value creation vs. simplistic notions of radiology value

•  Old PQRS system

•  New MIPS system


The McNamara Fallacy 1. Measure whatever can be easily measured 2. Disregard whatever cannot be measured easily 3. Presume that whatever cannot be measured easily is not

important 4. Presume that whatever cannot be measured easily does not

exist

Coined by sociologist Daniel Yankelovitch, cited at http://chronotopeblog.com/2015/04/04/the-mcnamara-fallacy-and-the-problem-with-numbers-in-education/ accessed on 3-23-2016


Value Chain for Radiology Services in the Early 21st Century

87


Value Chain for Radiology Services in the Early 21st Century

1. Consultation for appropriate imaging

2. Equipment and protocol optimization

3. Personalization of imaging 4. Clinical consultation with referring

medical professionals 5. Discussion of results with patients 6. Promotion of good health and

advocacy Copyright: Frank J. Lexa, M.D. M.B.A., 2016

The high value Radiologist

•  A priori involvement in decisions about imaging: who, when, how, what, etc.

•  Service metrics

•  Process and cost improvements

•  Customer satisfaction: patients, referring MDs, administrators, etc.

•  Much greater government and public involvement and oversight

Lexa, FJ and J Berlin “ACOs for neuroradiologists: threats and opportunities” in Socioeconomics of Neuroimaging, edited by David Yousem Neuroimaging Clinics of North America, August, 2012 volume 22, #3, pp 437-441


The high value Radiology Group

•  IT backbone for the health enterprise

•  Utilization Management – optimize imaging, consultation

•  Screening diagnostics for primary care physicians (and non MDs)

•  Quality and Service

•  Disease management

Breslau J. “The Opportunities for Radiology Participation in ACOs” Accountable Care News vol3, #8, August 2012, p. 1


Starting points for building value •  Going beyond the read •  Expanding the current value chain

•  Novel types of value •  CRM- building stronger bridges to our customers


System Synergies

•  More efficient diagnosis •  Chronic Disease management •  Co-Marketing •  Empowering primary care doctors •  Increase efficiencies of:

•  ICU •  ED •  Surgical suites

•  Improve communication and coordination through inpatient

and outpatient experiences


Practical projects to increase value •  Comparative effectiveness •  Increase the velocity of care •  Improve service •  Embedding radiologists (partly) •  Service lines •  Geographic and temporal matching

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Beyond Interpretations •  Assuring Appropriateness •  Documenting the Quality and

Patient Safety Radiologists Provide

•  Actionable Reporting with Evidence-based Follow-up Recommendations

•  Empowered Patients

Courtesy of ACR Copyright: Frank J. Lexa, M.D. M.B.A., 2016

The best questions to ask when you are “de-commoditizing” something are:

1. Who are the Customers 1.  Referring MDs

2.  Technologist

3.  Hospital and ACO administrators

4.  Patients and family

5.  Payors

6.  Government

300,000,000 Customers: Patient Perspectives on Service and Quality, Frank James Lexa, MD J Am Coll Radiol 2006;3:346-350, 2006


The best questions to ask when you are innovating are: #2 What do they want?

1.  What do they want?

2.  What could be better?

3.  What shouldn’t we do?

4.  What do you like about our competitors?

5.  What would help you do your job?

This creates a matrix of opportunities by

customer segment


What Should Radiology Groups Do?

1.  Don’t limit your value to film reading 2.  Put your patients first 3.  Pay very close attention to value based

schemes 4.  Listen to your customers 5.  Build bridges to health care providers 6.  Use the matrix to find novel ways to provide

services 7.  Keep innovating and improving

89

Non-Physician Providers: Opportunities and Challenges for Radiology

in our New Team Based World

Richard Duszak, MD, FACR, FSIR, FRBMA Professor and Vice Chair for Health Policy and Practice

Department of Radiology and Imaging Sciences Emory University School of Medicine

Disruptive Innovation

http://www.claytonchristensen.com/key-concepts/

A process by which a product or service takes root initially in simple applications at the bottom of a market and

then relentlessly moves up market, eventually displacing established competitors.

Non-Physician Provider Disruption

Christensen CM, et al. HBR 2000.

“Nurse practitioners are capable of treating many ailments that used to

require a physician’s care.”

“We need diagnostic and therapeutic advances that allow nurse

practitioners to treat diseases that used to require a physician’s care.”

Top 20 Most Requested Searches by Specialty

From Merritt Hawkins. http://www.forbes.com/sites/brucejapsen/2015/07/15/nurse-practitioners-physician-assistants-more-in-demand-than-most-doctors/

“Combined, physician assistants and nurse practitioners were fourth on the list... “Four years ago, neither NPs or PAs were among (the firm’s) top 20 assignments either collectively or individually.”

Who’s Not on That List?

“Radiology, which was Merritt Hawkins’ most requested specialty in 2001, 2002, and 2003 did not make the list of Merritt Hawkins’ top 20 most

requested specialties in 2013.”

Merritt Hawkins. 2013 Review of Recruiting Incentives.

Us!

The Impending Physician Manpower Shortage

  “The nation will face a shortage of between 46,000 to 90,000 physicians by 2025.”

  “The doctor shortage is real – it’s significant – and it’s particularly serious for the kind of medical care that our aging population is going to need.”

AAMC. https://www.aamc.org/newsroom/newsreleases/426166/20150303.html

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NPPs are Here to Stay!

Salsberg E. Health Affairs Blog. 5/26/15

“If these practitioners are fully integrated into the delivery system and allowed to practice consistent with their education and training, this growth

can help assure access to cost-effective care across the nation.”

Agenda

  Definitions   Training and licensure   Billing and compliance   NPPs within your practice

  Diagnostic radiology   Interventional radiology

  NPPs outside your practice   Closing thoughts

Non-Physician Providers

Nurses Technologists Physician Assistants

Radiologic Technologists

Radiologist Assistants

Registered Nurses

Nurse Practitioners





Registered Nurses

Nurse Practitioners

RA, RRA ,or RPA

PA

NP

Billing is Binary

Qualified Healthcare Professional

Clinical Staff

Member

Qualified Healthcare Professional

  A “physician or other qualified health care professional” is an individual who is qualified   by education, training, licensure/regulation (when applicable),and facility privileging (when applicable)   who performs a professional service within his/her scope of practice   and independently reports that professional service.”

CPT Professional Edition, 2015.

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Clinical Staff Member

  “A person who works under the supervision of a physician or other qualified health care professional and   who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service   but who does not individually report that professional service.”

CPT Professional Edition, 2015.

Independent Medicare Reporting

I’m not defining practitioner. Medicare is!













95









Registered Nurses

Nurse Practitioners





Registered Nurses

Nurse Practitioners

650

95,000

205,000

Shameless Self Referncing

NPPs in Radiology

  Radiologist assistants   Physician assistants   Nurse practitioners


  Two pathways:   RPA (Radiology Practitioner Assistant)   RA (Radiologist Assistant) → RRA (Registered Radiologist Assistant)

  Initial training as radiological technologists   Additional advanced radiology training

  Usually BS degree   Some states recognize separately from RTs   Medicare does not recognize as QHPs

96


  Two pathways:   RPA (Radiology Practitioner Assistant)   RA (Radiologist Assistant) → RRA (Registered Radiologist Assistant)

  Initial training as radiological technologists   Additional advanced radiology training

  Usually BS degree   Some states recognize separately from RTs   Medicare does not recognize as QHPs


  Only 9 approved RA training programs   Approximately 650 employed as RAs

  NPs: 205,000   PAs: 95,000

  Ready to go!   Many barium services   Many minor IR services

QHP

Physician Assistants

  Direct PA training pathway   Medical school “lite” pathway

  Masters in Physician Assistant Studies (MPAS), Health Science (MHS), or Medical Science (MMSc)

  No formally recognized training programs in radiology   Most states recognize PAs, but scope of practice varies   Medicare recognizes PAs as QHPs

Physician Assistants

  Direct PA training pathway   Medical school “lite” pathway

  Masters in Physician Assistant Studies (MPAS), Health Science (MHS), or Medical Science (MMSc)

  No formally recognized training programs in radiology   Most states recognize PAs, but scope of practice varies   Medicare recognizes PAs as QHPs

Nurse Practitioners

  Initial training as registered nurses   Additional advanced clinical nursing training

  MSN, but now many DNP programs

  No formally recognized training programs in radiology   Most states recognize NPs separately from RNs, but scope of practice varies   Medicare recognizes NPs as QHPs

Nurse Practitioners

  Initial training as registered nurses   Additional advanced clinical nursing training

  MSN, but now many DNP programs

  No formally recognized training programs in radiology   Most states recognize NPs separately from RNs, but scope of practice varies   Medicare recognizes NPs as QHPs

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Billing and Compliance Considerations

1.  Don’t submit false claims 2.  Physicians and NPPs get paid differently 3.  Appropriate supervision is critical 4.  NPPs are not trainees

Claim Submission 101

  Claims can only be billed for services provided in accordance with applicable laws, regulations and coverage policies.   All claims require an attestation that services were so rendered.   Claims submitted under false pretenses can be construed as “false claims.”

Don’t Be Him Only Physicians Get Paid 100%

  Both physicians and non-physicians are paid under the Medicare Physician Fee Schedule   Physicians are paid at 100% of MPFS   NPPs are paid only if recognized by Medicare, and then only at 85% of MPFS

  When thinking about billing for services, think carefully about who will be submitting the claim

Only Physicians Get Paid 100%

  Both physicians and non-physicians are paid under the Medicare Physician Fee Schedule   Physicians are paid at 100% of MPFS   NPPs are paid only if recognized by Medicare, and then only at 85% of MPFS

  When thinking about billing for services, think carefully about who will be submitting the claim

Medicare Supervision Levels

Indicator Definition Requirement

1 General Supervision Furnished under the physician’s overall direction and control

2 Direct Supervision Physician must be present in the suite and immediately available to furnish assistance and direction

3 Personal Supervision Physician must be in attendance in the room during the performance of the procedure

9 Concept does not apply Not a service for which supervision applies

Only physicians may supervise others!

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Medicare Supervision Examples

  General   Radiography   Non-contrast CT or MR

  Direct   Contrast enhanced CT or MR

  Personal   Most fluoroscopic guided procedures   Supervision and interpretation

  Does not apply   Minor or major surgical procedures

Supervise RAs Carefully

“ the limitations imposed on billing for the services they perform negatively

affect using the services of these professionals and

increase the level of physician involvement in

every clinical setting.”

Trainee Supervision

  “In order to bill for surgical, high-risk or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure.”   Teaching physician rules only apply to ACGME trainees!

Duszak R. JACR 2007; 4: 584-585.

Roles in Diagnostic Radiology

  Almost all NPP services are non-billable   That doesn’t mean that they’re not valuable!

  Value-added services   Interpretation services   Diagnostic fluoroscopy services

NPP Care Coordination

  Aligned with Imaging 3.0 “beyond the report” value added services   Triage and facilitation, utilization management, and care coordination

Zaidi S. JACR 2015.

Using care coordinators, we actively follow up on patients with suspicious neoplastic findings on cross-sectional imaging, both inpatient and outpatient, and expedite clinical consultation with oncologists. In 2014, compared with 2013, we were able to reduce time from initial imaging to biopsy by 3 whole days for inpatients by implementing this program. Not only did this patient-centric program decrease the length of stay and costs for our patients, it also decreased the likelihood that patients would be lost to follow-up. In the end, the group collectively achieved goal performance, made sustainable changes to the way lung nodule biopsies are performed, addressed referring physician and patient concerns, and lowered cost by reducing repeat biopsies, all while improving the quality of care.

NPP Preliminary Reporting

  In controlled environments   Quality is good   MD productivity improved   Turnaround times shorten

  General radiography, mammography, and emergency radiology

Kiiernan B & Rosenbaum HD. Invest Radiol 1977; 12: 7-14. Hillman BJ, et al. AJR 1987; 149: 901-911.

Blackmore CC, et al. JACR 2004; 1: 410-414.

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NPP “Barium Service”

  Gastrointestinal fluoroscopy services require personal supervision   Previously restricted to only the non-hospital

setting, but now applies to hospital services as well   Ability to bill for RA performed GI fluoroscopy

services is limited to only those cases where the physician provides personal supervision   Many quality, regulatory, and political obstacles

exist to NPs or PAs providing such services independently

Roles in Interventional Radiology

  Non-procedural clinical care   Procedural services

IR Clinical Services

  NPs and PAs can capably fulfill nonprocedural clinical duties vital to the day-to-day function of a procedural diagnostic radiology or an interventional radiology service

  Only selected services are billable   But, do not underestimate the huge value of non-billable services in terms of service, quality, and physician time

Billable vs. Non-Billable Clinical Services

  RAs cannot bill   NPs and PAs can bill for services, but only if they meet specific CPT Evaluation and Management (E&M) code guidelines   These guidelines are generally the same as those for physicians

Clinical Encounters: What’s Billable?

  New or follow up office patient   New or follow up hospital patient

  If an NP or PA performs the bulk of the encounter documentation, billing under his/her NPI (at 85% of MPFS) is probably most practical and compliant   15% “loss” is usually well offset by opportunity cost considerations

Clinical Encounters: What’s Not Billable?

  Services bundled into a procedure itself are never separately billable   Typical bundled services

  Routine paperwork   History and physical   Discharge coordination   Follow up planning

  But, still a great return on investment   Service and quality   Opportunity cost considerations

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NPP Procedural Safety

  Paracentesis (Gilani, 2009)   Non-targeted liver biopsies (Murphy, 2014)   Venous access (Silas, 2010; Benham, 2007)   Coronary angiography (Krasuski, 2003)

Expanding NPP Procedural Roles

Duszak R, et al. JACR 2013.

For non-implanted central lines, NPP “market share” increased from 0% in 1992 to 7% in 2011.

Expanding NPP Procedural Roles


Paracentesis 10.7%

Thoracentesis

5.7%

But, Battles Still Exist

  “Given the numerous hurdles involved in obtaining Medicare reimbursement, that percentage growth suggests an increasing national acceptance by institutional credentialing bodies, state licensure boards and payers alike.”   In credentialing NPPs, data will be your friend

  Procedure logs   National benchmarks


NPPs Outside of Radiology

Salsberg E. Health Affairs Blog. 5/26/15

“If these practitioners are fully integrated into the delivery system and allowed to practice consistent with their education and training, this growth

can help assure access to cost-effective care across the nation.”

NPP Roles Outside of Radiology

Christensen CM, et al. HBR 2000.

“We need diagnostic and therapeutic advances that allow nurse practitioners to treat diseases that used to require a physician’s care.”

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NPP Roles Outside of Radiology NPP Imaging Ordering

Hughes DR, et al. JAMA IM 2015.

•  2010-2011 Medicare 5% Research Identifiable Files •  8,114,207 outpatient E&M visits •  For acuity matched encounters, NPPs 1.3x more likely to order imaging

The Case for Clinical Decision Support? Summary

  Disrupt or be disrupted   NPPs can enhance your practice in many ways

  Some are financially quantifiable   Many are not

  As medicine increasingly becomes a team sport, NPPs will become increasingly relevant, both within your practice and from outside   Accept reality and proceed accordingly

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Why Is Culture Change So Difficult, Yet So Important?

Lawrence R. Muroff, M.D., FACR CEO & President

Imaging Consultants, Inc.

4/28/16 Culture Shift an Imperative for Future Survival

1

What Is Culture?

Culture is the way that a like-minded group of individuals think and act. The “culture of radiology” has both good and bad elements.


2

Radiology Culture- The Good 1) Democratic (often to a fault)

a) Equal voice, vote, and income stream

2) Low buy-ins to attract the “best and the brightest”

3) Outstanding quality of life 4) Continually changing technology

(intellectually challenging) 4/28/16 Culture Shift an Imperative for

Future Survival 3

Radiology Culture- The Bad

1) A mixture of denial and entitlement 2) Dysfunctional groups

a)  Inability to make rapid decisions b) Reluctance to deal with

problematic partners/associates 3) A resistance to needed change


4

Why Do We Have to Change?

1) What will the practice of radiology look like in the near future (particularly if we don’t change our behavior)?

2) What are the trends that will influence what we do and what we earn?


5 4/28/16 Culture Shift an Imperative for Future Survival

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If we want to prepare for the future, we have to know what it will look like


7

Radiologists tend to look backwards, not forward.


8

Wouldn’t it be great if 2016 (and beyond) looked like 2009- or better yet, 2005?


9

It would be great, but it’s not going to happen!


10

2 Different Views of Radiology


11

Dr. Ben Strong- CMO vRad 1)  Clinicians don’t care about talking to you

or having you talk to their patients- I know; I once was a clinician

2)  The only thing that radiologists do of importance is to provide an interpretation

3)  The site where that interpretation is generated is irrelevant, as long as it is timely and accurate

4)  Imaging 3.0 is dead on arrival 4/28/16 Culture Shift an Imperative for

Future Survival 12

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Dr. Bibb Allen- Chair, ACR BOC 1)  Radiologists must be visible to our

patients and our referring physicians 2)  We must add value to the diagnostic and

therapeutic approach to our patients 3)  We should be active participants in the

decision-making and strategic planning of our hospitals

4)  Imaging 3.0 provides a blueprint for our actions and those of our specialty


13

Which view of radiology do you embrace? Do you believe that neither position is valid and that you can practice as you have in the past and still survive/thrive in the times ahead?


14

Many radiologists hope that Dr. Strong is wrong and that Dr. Allen’s view is the correct one. A large segment appears to believe that doing nothing would be the “path of least resistance” and certainly would be the option of choice for them. 4/28/16 Culture Shift an Imperative for

Future Survival 15 4/28/16 Culture Shift an Imperative for

Future Survival 16

Radiologists have had it too good for too long- David C. Levin, M.D., FACR Emeritus Chair, Thomas Jefferson



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• Full-size image - Same sizex larger This image may be subject to copyright.

Radiology’s “cheese” has been moved, and radiologists are being forced to confront non-traditional issues, protect against aggressive competition, and cope with practice-threatening trends.


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This is not the time for “business as usual”; however- 95% of ACR Councilors said (May 2012 AMCLC) that they believed that radiologists would not change until the pain of the status quo far exceeded the potential pain of changing. 4/28/16 Culture Shift an Imperative for

Future Survival 21

What Is the Argument Against Doing Nothing?

1)  Reimbursement is declining and “increasing productivity to compensate” is a failed strategy

2)  Radiologists are losing their hospital contracts in record numbers throughout the country

3)  National entrepreneurial entities are aggressively pursuing hospital contracts and sometimes getting them


22

What Is the Argument Against Doing Nothing?

4) Alternative payment models are mandating a” different” approach to patient care

5) If we don’t participate as active team members and show value/ significance in the new health care environment, then others will be happy to take what we have- and in many cases they will be able to do so

Culture Shift an Imperative for Future Survival

23 4/28/16

What does it take to change culture?


24

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Kotter’s Elements to Facilitate Change

1) Establish a sense of urgency 2) Create the guiding coalition 3) Develop a vision and strategy 4) Communicate the change vision 5) Empower broad-based action


25

Kotter’s Elements to Facilitate Change

6) Generate short-term wins 7) Consolidate gains and produce more

change 8) Anchor new approaches in the

culture


26

The future for Radiology is bright; the future for radiologists is far less certain. L. R. Muroff, M.D., FACR


27

Urgency Before Disaster 1)  Radiologists tend to be complacent, in

denial, or embarrassed 2)  Too often they don’t ask for help until

problems have progressed to the point that an RFP is either in process or ready to be sent

3)  The best way to prepare for problems is to deal with them as hypotheticals

4)  Scenario planning is ideal to do this 4/28/16 Culture Shift an Imperative for

Future Survival 28

Opportunities and Issues

1) Alignment 2) Mergers, affiliations, aggregations 3)  Income diversification 4) Service, quality, safety 5) Communication, education


29

Alignment


30

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Alignment

1) Take sides- our system or theirs

2) Sell your outpatient imaging offices

3) Become employed


31

SLED DOG ANALOGY


32

National Entrepreneurial Radiology Companies: Aggressiveness with a tinge of desperation.


33

What Do These Companies Offer to a Hospital?

1)  Less or no problematic radiologists- if a problem occurs, that radiologist is gone

2)  Quality metrics on a monthly basis 3)  24/7 sub-specialty expertise 4)  Savings because there is no need for

transcriptionists 5)  Savings (in the future) on equipment, etc. 4/28/16 Culture Shift an Imperative for

Future Survival 34

Radiologists must offer what these companies offer or risk losing their hospital contracts.


35

Alternative Payment Models

Fee for service has worked very well for radiologists; however, it is clear that practices (and hospitals) will have to cope with a variety of alternative payment methodologies. Bundled payments, capitation “offshoots”, and ACO options are “just around the corner”. 4/28/16 Culture Shift an Imperative for

Future Survival 36

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The concept of “professional payment bundling” is being pushed hard by health care theorists. This will accelerate the move to the employment model. Hospitals will begin to be more aggressive in pressuring their radiology groups to become employees, and some radiologists willingly agree. 4/28/16 Culture Shift an Imperative for

Future Survival 37

Why will hospitals want to employ radiologists?


38


39

Basically, it is easier to split the bundled dollar if everyone is employed. The “trick” for radiologists who want to remain independent will be to have the data and the knowledge necessary to do so. 4/28/16 Culture Shift an Imperative for

Future Survival 40

So, what’s the bottom line for radiology and radiologists in the near future?



42

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In the old days, all we wanted was to get our slice of the pie. Now we have to understand that the pie is going to be smaller, so to stay the same, we will have to get a bit of someone else’s piece. If we want to grow we will have to develop a different type of pie. 4/28/16 Culture Shift an Imperative for

Future Survival 43

In the past, virtually all radiologists were winners (although to different degrees); now and in the future, there will be winners and losers.


44

In the past, it took work to fail; now and in the future, it will take work to succeed.


45

Conclusion 1) What we have now is not guaranteed. It will

take work and planning to have a successful practice.

2) We have to optimize the operations of our

practices (academic and private) to compensate for declining reimbursement.

3) Income diversification will be a must for future

success 4/28/16 Culture Shift an Imperative for

Future Survival 46

Conclusion 4) If we continue with “business as usual”, there are others who would gladly take what we have- and they will.

5) We have few friends at the national level; therefore, we must “play by the rules”. PACS involvement is essential.


47

Conclusion 6) The shift from “volume to value” and from “output to outcomes” is not optional. These phrases describe the inevitable result of alternative payment models. Radiologists will have to be significant or we will be irrelevant.

7) A shift in “culture” is not a luxury; rather, it is an imperative for professional survival. 4/28/16 Culture Shift an Imperative for

Future Survival 48

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Are you and your colleagues up for the challenge?


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